By Amanda Frost, Eric Barrette, Kevin Kennedy, and Niall Brennan
Health Affairs, September 19, 2018

Abstract

Using a national sample of health care claims data from the Health Care Cost Institute, we found that total spending per capita (not including premiums) on health services for enrollees in employer-sponsored insurance plans increased by 44 percent from 2007 through 2016 (average annual growth of 4.1 percent). Spending increased across all major categories of health services, although the increases were not uniform across years or categories. Growth rates for total per capita spending generally slowed after 2009 but increased between 2014 and 2016. Spending on outpatient services grew more quickly (average annual growth of 5.7 percent) compared to spending on the other types of services. However, the overall distribution of spending across categories remained largely unchanged. In the context of the dramatic economic and policy events that have taken place since 2007—including the Great Recession, the Affordable Care Act, and numerous medical innovations—this assessment of ten-year spending trends provides insights into how the largest insured population in the US contributes to health care spending growth.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Previously much of our access to data on health care spending has been through government programs – Medicare and Medicaid. Data on commercial insurance spending, especially employer-sponsored plans, were hidden in a cloud of secrecy as proprietary information. Now a group of major insurers has made that information available though the Health Care Cost Institute. Having this information is helpful because it can reveal underlying health care spending trends in the very large sector of commercial insurance (covering 54 percent of Americans) that was not disturbed by the Affordable Care Act (ACA).

In the decade that included the Great Recession and the enactment and implementation of ACA, there was an initial slowing in the rate of health care spending increases. The ACA enthusiasts were quite willing to take credit for that slowing, though there was not much evidence that the specific polices contained in ACA could be credited for it. It seemed much more likely that the slowing in health care spending growth was merely a manifestation of the global slowing of the economy during the recession.

In the latter part of the decade studied, health care spending growth increased again. Although ACA is still in force, this increase further suggests that the previous slowing was due to the recession and not due to any magical policies contained in ACA. In fact, many other studies have demonstrated disappointing results in the ACA measures that were supposedly designed to contain spending.

The significance of this is that it is wrong to continue to support ACA based on the concept that we merely need to give it more time to work, maybe while adding a public option – an option that would not change in any fundamental way the huge, highly dysfunctional, fragmented infrastructure of our health care financing system. It is wrong to reject a proven model that would be effective in reducing the rate of spending increases to sustainable levels – a single payer national health program.

Now that we have opened the Pandora’s Box of private commercial insurance data, we have confirmed that private insurance is not capable of containing the excessive growth in health care spending. So let’s move forward with establishing our own public program that would work – a single payer improved Medicare for all.

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NORC at the University of Chicago, September 13, 2018

Three-quarters of Americans consider the cost of prescription drugs in the United States to be “unreasonable,” and despite promises from the President and members of Congress to rein in prices, few approve of either’s handling of the issue, according to a new national poll from the West Health Institute, a nonpartisan, nonprofit healthcare research organization, and conducted by NORC at the University of Chicago.

The survey found the high cost of healthcare is a top public policy issue for Americans. When presented with a list of six issues, 78 percent said addressing healthcare costs was their highest priority, similar to the number who say the same about jobs and the economy (76 percent), and ranking higher than national security (71 percent), the environment (63 percent), immigration (51 percent), or trade (38 percent).

High prescription drug prices are a particular worry for most Americans. Sixty-five percent said they are extremely or very concerned about the issue. Another 88 percent said lowering medication costs should be a top priority for candidates running for Congress.

From the Survey:

To reduce the cost of prescription drugs, should…?

82% – Medicare be allowed to directly negotiate with drug companies to get lower prices on prescription drugs

82% – More lower-cost generic prescription drugs be allowed to compete with the equivalent high-cost brand name prescription drugs

80% – Drug companies be required to release information to the public on how they set their prices

65% – Americans be allowed to buy prescription drugs from Canada

52% – Prescription drug advertisements be eliminated

31% – Drug companies be required to set the price for a drug based on how well it works

Press release:
http://www.norc.org…

Full issue brief and results:
http://www.norc.org…

Topline:
http://www.norc.org…

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Comment:

By Don McCanne, M.D.

Not only do Americans object to the high prices of prescription drugs, they also feel that the President and members of Congress have failed us in not doing more about it.

When offered a list of various options on what we can do, to no surprise at the top was that Medicare should be allowed to negotiate for lower drug prices (along with more generic drug competition and more transparency in the setting of drug prices). Again, Americans support a major government role in drug pricing.

With the current popularity of Medicare for All it would have been interesting to see how strong the support would have been for including drugs as a benefit of an improved Medicare that covered everyone, but they didn’t ask that. Regardless, if we already had in place a comprehensive, single payer, improved Medicare for all that included a drug benefit, there is no question that it would be extremely popular.

We hear the opponents of reform talk about how bad the systems in Canada and Great Britain are, yet we hear from their people that they would never consider transforming their systems into one like ours. Since the majority of our politicians continue to fail us, it seems that we should replace them with leaders who can hear our message.

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By Leemore Dafny, Ph.D. and Namita Seth Mohta, M.D.
NEJM Catalyst, March 2018

Health care stakeholders are not aligned in important goals and in large part are not working together to achieve value-based care, according to the NEJM Catalyst Insights Council. They are waiting on government regulators to change the payment model – including, possibly, single-payer health care.

More than half (58%) of Insights Council survey respondents indicate that their individual organizations are not aligned in working toward achieving value-based care. A higher percentage of clinicians (63%) than clinical leaders (53%) think that payers and providers at their organization are not aligned. At the health care industry level overall, the outlook is even bleaker, with 77% reporting a lack of alignment.

Unlike many industries where the private sector typically takes the lead in driving change, our survey confirms other research that in health care, government payers set the blueprint for private payers to piggyback on. Respondents rate regulatory payment model changes (such as from Centers for Medicare & Medicaid Services) as the most influential among drivers to improve payer-provider collaboration.

Single-Payer Health Care Would Have a Positive Effect on Value-Based Care

Would the ability to provide value-based care get better, worse, or stay the same under single-payer health care?

61% – Better
22% – Worse
16% – Stay the same

Single-payer health care would have a strongly positive impact on the ability to provide value-based care, say Insights Council respondents. This reaction is consistent across all three audience segments of executives, clinical leaders, and clinicians. In verbatim responses, many respondents single out single-payer as the systemic change that would most improve payer-provider collaboration. These results continue the trend that NEJM Catalyst has observed among Insights Council members holding a positive view of single-payer health care.

https://cdn2.hubspot.net…

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Comment:

By Don McCanne, M.D.

In the quest to change from volume to value in health care financing, gimmicky models such as accountable care organizations are being implemented, but the lack of alignment between payers and providers has not achieved the goal of value-based care. This survey of clinicians, clinical leaders and executives reveals that they believe that a single payer approach would have “a strongly positive impact on the ability to provide value-based care.”

Rather than continuing on the path to nowhere laid down by the politicians, bureaucrats, and policy community, doesn’t it seem logical that we should look at the model that those in the trenches – the clinicians, clinical leaders and executives – believe would actually work? Rather than having the payers attempting to align the providers, we should be having the providers who understand the delivery of health care give guidance to the design of the financing system. It becomes ever more evident to those providing the care that instead of a fragmented, dysfunctional market of private payers we should have a single, efficient public payer if we want to inject greater value into our health care system.

It would be infinitely better for the providers to give guidance to the design of the financing system to make it work optimally for patients than it would be to continue to allow the payers to try to design the health care delivery system. That’s how we have ended up with MACRA, MIPS, APMs, ACOs and other screwball ideas. Let’s work on improving the clinics and hospitals instead – under a single payer system. That’s where the value is.

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By Don McCanne, M.D.
September 17, 2018

In the big picture of health care in America, the following anecdote is quite trivial, but, as I’ll explain, the implications are of great consequence.

Through the years my wife and I have had great care coordinated by our highly competent primary care physician. He retired recently and his practice was taken over by another physician. I needed a refill on my two blood pressure medications, but rather than interacting with the physician, I was now interacting with OptumCare Medical Group, a subsidiary of UnitedHealth. (You’ve no doubt read about insurers consolidating with physician groups – it’s very real.) Although we have avoided the private Medicare Advantage plans, I found by perusing OptumCare’s website that, without my knowledge, I was assigned to their Medicare Pioneer ACO.

The trivial complaint of mine is that I had to have numerous contacts through an always-busy telephone system and a non-responsive contact point on their website which resulted in many days of effort just trying to get my two basic blood pressure medications refilled. Several errors were made and, in fact, they never were correct even after repeated attempts. The prescriptions had the names of two different nurse practitioners on them, and finally one had the name of my new primary care physician after I was finally able to see him. Part of these glitches were due to the fact that they were transitioning to a computer system.

Not only were my prescriptions under the control of OptumCare, I was also covered by a Part D Medicare drug plan through Anthem Blue Cross. All I wanted was a 90 day supply of each pill with 3 refills, just as I had had under our previous physician. Well, somewhere between OptumCare and the Anthem drug plan, our independent pharmacist of many years was authorized to fill only a 30 day supply, but for only one of them since it was too early to fill the other one. This meant that I would have to come back every 15 days indefinitely to pick up only one prescription at a time. I checked the Anthem website and found that not only was my pharmacy not on the preferred list, it was no longer listed in the Anthem network at all (with a statement that pharmacies could be changed at any time without notice).

I discovered that I could receive 90 day supplies by mail through Anthem’s pharmacy benefit manager, but it seemed unfair to me that they should take over the bread and butter trade of easy long term prescriptions while leaving the local pharmacist with the need to carry a huge stock of a great variety of prescription items that are filled usually only once, creating an overhead headache without a volume offset.

I finally gave up. Since I still have my medical license, I ordered stock jars of 1000 pills each through a medical supplier so I wouldn’t be bothered with the hassle any more (a strategy not available to most people). Of course, that’s not covered by the Part D plan, but I had had enough. (I should mention that though it is unethical for a physician to prescribe for himself, these two medications were actually prescribed by my primary care physician and by my cardiologist.)

Yes, this is very trivial compared to some of the horrendous problems that others face in our health care system. But it is what this annoyance represents that is so objectionable. The system should work so that I can get my very common, tier one generic medications every three months with an effortless system of refilling them. Instead, my physician has been hijacked by one of the largest insurers in the nation, and my pharmacist has had barriers erected by another of the largest insurers, together making it much more difficult for me to obtain my straightforward maintenance medication. What value are these giant insurers adding that we should have to tolerate their inanity?

The reason that everyone should be concerned is that this takeover of health care is expanding rapidly, with no relief in sight. If it doesn’t work well for minor routine matters, how could it work well for the big stuff? A well designed, single payer improved Medicare for all program as is advocated by Physicians for a National Health Program would solve most of the problems with our highly dysfunctional health care financing system. Although there is widespread public support for such a model of reform, look very carefully at what is actually happening in the political arena.

Congress and the administration are continuing to expand the private Medicare Advantage and private Medicaid managed care models. They are continuing to push alternative payment models including accountable care organizations and other so called value-based proposals that involve intrusions by insurers and other managers. While using the Medicare for all rhetoric, they are quietly suppressing the bona fide single payer model while giving the business intermediaries an even greater role in (mis)managing our health care system.

HR 676, the Expanded and Improved Medicare for All Act contains many of the principles of a well designed single payer system. People are enthused to see the formation of a Medicare for All caucus in the House. There has also been considerable enthusiasm over the introduction in the Senate of Bernie Sanders’ bill, S 1804, as supposedly being a single payer Medicare for All bill in the Senate. However, to gain cosponsors, many compromises were made. Exemplifying them is the inclusion of the following:

“Sec. 611 (b) Application Of Current And Planned Payment Reforms.—Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act, including any reform activities or demonstrations planned or implemented under the provisions of, or amendments made by, the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10) and the Patient Protection and Affordable Care Act (Public Law 111–148).”

This means that the payment models of ACA and MACRA with MIPS and APMs including ACOs would be perpetuated under S 1804. What is especially alarming is that members of the House Medicare for All caucus, instead of protecting and supporting the single payer features of HR 676 and encouraging the Senate to endorse the same, they want to change HR 676 to include the highly flawed features of S 1804. It appears that the intent of Congress is to perpetuate the entities that are creating many of the very problems that we are trying to solve with PNHP’s version of an improved Medicare for all. Leaving our dysfunctional system in place while merely adding a Medicare Advantage-style public option is no solution at all.

My wife and I have transferred our care to another excellent physician. We left OptumCare but are continuing with the traditional Medicare program with a Medigap supplement to protect us in the event of catastrophic events. We also are continuing with our Part D drug plan to protect us against the potential of those $100,000 drugs that are becoming so commonplace. But wouldn’t it be nice to have the Medigap benefits and the drug benefits rolled into the traditional Medicare program along with the other improvements that would be ideal in an improved Medicare for all? We’re not going to have that unless we start communicating more effectively with our members of Congress, even if it means using our boot.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Texas Medical Center Health Policy Institute
Survey completed June-July 2018 (4,020 national participants)

Support for Medicare for All U.S. Adults

Q: Are you in favor of the federal government providing Medicare insurance coverage for all U.S. adults?

59% – All
71% – Democrats
46% – Republicans
55% – Independent

http://www.tmc.edu…

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Comment:

By Don McCanne, M.D.

Although this question asks about providing Medicare insurance coverage for all U.S. adults without mentioning children, nevertheless it still shows strong support for Medicare for all, including close to one-half of Republicans.

Efforts are being made to discredit these surveys by tacking on questions such as “even if it means the government raising your taxes,” or “even if it means losing your choice of health plans,” or “even if it means they take away your insurance through your work.” Inevitably these questions slightly reduce polling support for Medicare for all.

Polls that we don’t see are those that would tack on questions that would increase the credibility of the Medicare for all model. Instead of threatening an increase in taxes, suppose they were asked, “even if it meant that all but the very wealthiest would end up paying on average less overall for health care.” Instead of threatening loss of choice of health plans, suppose they were asked “even if it meant that you would no longer be limited to a list of physicians and hospitals dictated by the insurer but rather you had complete free choice of your health care professionals and institutions.” Instead of threatening loss of your health plan through work, suppose they were asked, “even if it meant that you would never have to worry about health insurance again because you would automatically have full comprehensive coverage for life.”

Obviously we could go further. “Even if Medicare for all meant that we would save hundreds of billions of dollars in administrative waste.” “Even if Medicare for all meant that nobody would ever have to go without care because they couldn’t afford it.” “Even if it meant that wherever you are in the country, you would never have to worry whether your insurance is good.” “Even if it meant that you would never have to busy yourself with insurance paperwork because coverage and billing is automatic.” “Even if it meant that you would not have to worry about whether you could afford the care you are about to receive since out-of-pocket costs would be eliminated for all essential health care services.”

Well, the good news is that people are gaining a better understanding of the benefits of the Medicare for all single payer model. Republican voters are realizing that the Republican promise of a better replacement for Obamacare proved to be false, and yet they understand that we need more than what the Affordable Care Act brought us. Democratic voters largely understand the benefits of single payer, but they are just beginning to realize that some Democratic politicians are using the Medicare for all rhetoric deceptively to maintain the status quo that caters to the insurers and pharmaceutical firms. It is no wonder that we are seeing an increase in independent voters who are wary of both major parties but who also seem to understand that Medicare for all seems to be a much better option than our current dysfunctional system.

We need to keep on with what we’re doing, except do a whole lot more of it. Maybe those of us who are octogenarians will no longer have to say, “but not in my lifetime.”

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By Edward R. Berchick, Emily Hood, and Jessica C. Barnett
United States Census Bureau, Current Population Survey Annual Social and Economic Supplement (CPS ASEC), September 2018

In 2017, 8.8 percent of people, or 28.5 million, did not have health insurance at any point during the year. The uninsured rate and number of uninsured in 2017 were not statistically different from 2016 (8.8 percent or 28.1 million).

https://www.census.gov…

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Comment:

By Don McCanne, M.D.

This definitive report on the health insurance status of U.S. residents provides an extensive breakdown of the statistics on insurance coverage, but the one highlight above pretty well summarizes the status. There was no statistically significant change in the numbers of uninsured between 2016 and 2017.

Although the reported change from 28.1 million to 28.5 million uninsured may not be statistically significant, there are likely 400,000 people out there who personally believe it is significant for themselves even if the statistical analysis is dismissive of it. At any rate, there are still over 28 million people who can’t be pleased with their lack of insurance coverage.

The major lesson in this report is that the gain from the Affordable Care Act has appeared to plateau, although the numbers may not have fully stabilized yet, largely because of the policies being adopted by the Trump administration and the various state governments. But it is safe to say that complete elimination of uninsurance is not imminent and cannot possibly occur without a major policy change.

One of the least promising policy changes would be a Medicare public option, or Medicare buy-in, which some have mislabeled as Medicare for All. It would provide only one more option in the market of plans that already exists and thus would have very little impact on overall coverage or affordability since the other options are already available.

Of course, the most promising policy change under consideration that would be fully effective would be a single payer national health program – a bona fide Improved Medicare for All.

It has now been a decade since we started down the path of Obamacare. Regarding the goals of universality, equity, affordability, administrative efficiency, and guaranteed lifetime coverage, it is clear that the Affordable Care Act has been a failure. Rather than merely adding a Medicare Advantage-like public option to our expensive but mediocre system, we should finally provide the fix our system truly needs – an Improved Medicare for All. Just make sure it’s the real thing.

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